Job Details
JOB SUMMARY AND ESSENTIAL FUNCTIONS: Serves as charge nurse and assists in supervision of patient care by coordinating, implementing and monitoring shift activities to provide optimal patient care. Assigns duties/activities to professional/ancillary staff based on the patient's acuity level in accordance with established policies and procedures for effective utilization of patient care givers, supplies and equipment. Provides nursing care and performs activities of staff RN.
- Ensures continuity of appropriate patient care by planning staff assignments, providing direct patient care, and evaluating outcome of care within assigned unit. Coordinates, implements and monitors shift activities to facilitate efficient unit operations and ensure that patient care plans are maintained. Assists in the formulation and implementation of unit specific procedures and policies.
- Assesses the patient's physical, emotional, and social circumstances; makes nursing rounds; determines if planned or required care has been provided; makes individual decisions and referrals to other services for the patient's well-being; and participates in patient-centered staff conferences.
- Develops, assigns and/or reviews the development and modification of plans which provide safe nursing care.
- Serves as the unit liaison and resource nurse-in-charge, exchanging information with staff and physicians. Contacts other services for specialized treatment, tests, facilities, equipment and material support to the unit.
- Maintains safety and control of patients, employees and visitors in the unit. Investigates and prepares reports on accidents and other incidents involving patients, employees and visitors.
- Performs duties of Staff Nurse and other nursing personnel as needed.
- Makes daily staffing adjustments, assigns work to professional/ancillary staff according to patient acuity levels to ensure that all work is performed and in accordance with established policies, procedures and standards of care.
- Assigns employees daily to perform tasks on the basis of available skills and with consideration for the needs of each patient; sets priorities and redirects employees to other tasks as the need arises.
- Oversees the work of nursing personnel and instructs them in providing technical care such as the administration of drugs and the setup, regulation and monitoring of intravenous and other equipment. Reviews observations and nursing interpretation of patient data and condition and interpretation of electronic and other instrumentation displays.
- Collaborates with manager and educator to facilitate assignment of new employees for in-service instruction and orientation.
- Assists in the orientation and oversee the supervision of students when they provide patient care, treatment, and services as part of their training.
- Verifies that all nursing tasks and ordered medical treatments/ diagnostic procedures have been performed and documented in the medical record.
- Demonstrates knowledge of fiscal management process and makes decisions which utilize resources effectively. Applies cost effective measures in the utilization of personnel, supplies and equipment and ensures charges are captured for services provided.
- Answers inquiries; communicates and interprets policies, procedures and standards of practices to staff/patient/family/visitors to promote understanding and ensure consistency in the application of policies and procedures.
- Interprets nursing goals, policies and procedures governing nursing security, safety and visiting conditions to employees, patients and visitors.
- Investigates and answers queries from physicians, patients and visitors about patient care.
- Resolves complaints, conflicts and operational problems. Informs Nurse Manager/Nursing Clinical Supervisor of any problems or issues which cannot be resolved or require intervention.
- Identifies problem, documents resolution and communicates to applicable parties to ensure that operational issues are handled and resolved in a timely manner.
- Interpreting nursing, personnel and other applicable administrative polices, takes personnel/disciplinary action as needed at the time of infraction and in consultation with the Nurse Manager. Follows up with Nurse Manager regarding employee performance, any employee action taken and/or to recommend disciplinary action.
- Provides nursing care according to medical regime and the nursing intervention appropriate for the patients' conditions and according to established standards, policies and procedures including care of the ambulatory/clinic patient.
- Initiates assessment based on the patient's presenting problems or needs, the physician's medical diagnosis and the functional health framework upon clinic visit.
- Collects key information from patient, family, laboratory, and other medical reports. Ensures that all consents necessary for treatment/procedure have been signed and that all prescribed identification procedures have been carried out.
- Determines nursing diagnosis and priorities for care with special consideration given to patient teaching, discharge planning, and the growth and development needs of the patient.
- Determines which standards of care and practice apply to the patient.
- Documents assessment, including nursing diagnoses or other clinical judgments.
- Demonstrates knowledge and technical, interpersonal and critical thinking skills to provide care, manage clinical competency and meet age-specific patient needs within the unit.
- Manages the movement of patients to achieve an even flow and maximize the use of physician's time.
- Completes ongoing assessments according to policy and/or as determined by patient condition:
- re-prioritizes care based on new information,
- continues to update nursing diagnoses, and
- involves family and/or other significant individuals in assessment activities.
- Assesses, plans and implements care of assigned patients. Performs therapeutic nursing interventions:
- as ordered by the Physician
- consistent with primary and population-specific standards of care and practice
- with consideration given to knowledge gained from the initial and ongoing assessment of the patient
- consistent with nursing division policies and procedures, demonstrated competencies, and with consideration given to risk management, infection control practices and patient safety practices
- consistent with the nature of the unit:
- completion of history and physical assessment
- administration of medication, treatments and immunizations
- prepares patient for examination/procedures; positions and drapes patients
- pain control interventions
- provides assistance during examination/procedures
- removes and applies bandages and removes sutures
- orthopedic stabilization
- collects and labels specimens of blood, urine, feces and sputum and makes smears for cultures
- monitors patient responses during treatment/procedure (checks temperature, pulse, blood pressure and respiration)
- initiates corrective action whenever information from monitoring or life support equipment shows adverse symptomatology such as respiratory or cardiac insufficiency.
- coordinate patient referral
- patient education
- discharge instructions
- Determines the impact of nursing interventions on the patient's condition and recognizes the patient's progress towards meeting desired outcomes.
- Documents care based on standards of care and practice and/or clinical priorities for documentation including:
- assessment and ongoing assessment findings
- updated clinical priorities for documentation
- therapeutic nursing interventions with special attention to patient education
- patient's response to interventions and progress towards outcomes are noted
- Demonstrates ability to manage the care of patients with conditions common to the unit, including:
- care of patient with medical, surgical or orthopedic conditions
- care of unscreened sick or walk-in patients
- care of patient with altered mental status
- Prepares equipment/supplies and assists physician during treatments, procedures and examinations.
- Responds and/or participates with medical emergencies. Initiates and/or assists with CPR/BLS as required.
- Provides teaching to patient/family in the care of disease/condition. Develops and implements patient teaching outlines including objectives, content, teaching strategies and evaluation of patient progress.
- Maintains patient medical records; documents patient status and care given; performs charting duties; records activities and observations. Utilizes patient computer systems to enter and retrieve data.
- Confers and works collaboratively with patient/family/hospital staff regarding all aspects of patient needs (i.e., patient admission/discharge of/transfer process, discharge planning, referrals, coordinating exams/therapy/rehab, requisitions supplies, obtains medical records, etc.) in a customer responsive and courteous manner, in compliance with iRESPECT Standards and promoting patient/customer satisfaction.
- Transports monitored patients, specimens, equipment and supplies to and from various areas.
- Collaborates with forensic team and security to provide safe environment for patients in custody.
- Completes required continuous training and education, including department specific requirements.
- Attends staff meetings, all mandatory in-service, and additional continuing education as required.
- Contributes to the annual review of unit-based scope statement and determination of important aspects of care for clinical review.
- Assists in the development of indicators, thresholds, study methods, and data collection as assigned.
- Responds to problems/opportunities to improve care.
- Supports and is involved in the organization's Performance Improvement initiatives.
- Participates in and maintains competencies required for the position.
- Maintains a clean, orderly, safe environment for patients and personnel. Adheres to established policies, compliance/quality improvement, and safety, environment and infection control standards.
- Prepares and maintains required records, reports and files for administrative and compliance purposes.
- Represents the unit through involvement on interdepartmental and interdisciplinary committees or task forces.
- Performs other duties and responsibilities as required.
MACHINES OR EQUIPMENT OPERATED: Nursing and patient care equipment utilized in the performance of the duties of the Registered Nurse including , i.e., IV regulators, chest tube attachments, epidural pumps, BP and oxygen monitors, Dinemaps and portable manual blood pressure cups.
JOB REQUIREMENTS: EDUCATION: Graduate of an approved nursing school/program. Additional training/certification may be required in area of specialization. Qualified by education, training or experience to work with the school age, adolescent, adult and/or geriatric patient population as specialty assignment dictates.
EXPERIENCE: Two (2) years clinical experience; charge nurse experience preferred.
LICENSE OR CERTIFICATION: Registered nurse licensure to work in state of TN. Current CPR/BLS certification required.
KNOWLEDGE, SKILLS & ABILITIES: - Thorough knowledge of current nursing practices.
- Ability and willingness to apply nursing knowledge and skills and maintain clinical competency as required within area of assignment.
- Ability to manage a sometimes chaotic work environment related to changing patient needs, including work with patients with acute, chronic, and complex disease processes.
- Demonstrated skill in the use of applicable equipment; mature judgment and initiative required; is able to work without direct supervision; shows professional interest through self-development, continuing education, and involvement in professional organizations; presents a positive attitude and professional appearance.
- Ability to give and follow written and oral instructions.
- Ability to communicate effectively with others.
- Ability to react and perform under stress in emergency situations.
- Ability to effectively record and reflect observations.
- Ability to plan and organize work for self and others.
- Ability to exercise analytical judgment on work to be done.
PHYSICAL DEMANDS: Prolonged standing and walking; lifting, turning patients and equipment; repeated bending, squatting and stooping; exposure to infectious agents. Visual acuity is needed to assess color changes to verify accuracy of written materials and to administer and accurately prepare medications. Heavy Work - Exerting up to 150 pounds of force occasionally, and/or up to 75 pounds of force frequently, and/or up to 30 pounds of force constantly to move objects.
(May be further defined as "with or without assistance.")